| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy is not fully identifying or managing the risks associated with its services. It does not make contemporaneous Responsible Pharmacist (RP) records and it does not keep its RP records in line with requirements. Its team members are undertaking tasks that they should not be undertaking in the absence of an RP. And the pharmacy cannot show that its team members have read the pharmacy's Standard Operating Procedures. This means that team members may not always be working in the most safe and effective way. |
RP logs are now maintained only via our PMR system RxWeb, which records real-time entries and supports audit trails. Pharmacists have been trained in its use and compliance is monitored weekly. SOPs have been read and signed by all staff, and future SOP sign-off will be incorporated into staff inductions and SOPs will be reviewed every 2 years. We plan on making digital SOPs with read-receipt tracking which will enhance accessibility and compliance monitoring. This process may take a few months to fully implement but current hard copies are available on premises for staff to access. Posters reminding staff of RP absence restrictions are now permanently displayed |
28/07/2025 | 23/07/2025 |
| 1.3 | The pharmacy does not have sufficiently robust systems in place to ensure team members understand and adhere to restrictions on permitted activity when there is no RP present. |
All team members have undergone scenario-based training regarding RP absence rules, with assessment records retained. Quarterly spot audits by the Superintendent Pharmacist will ensure continued compliance. Visual reminders remain displayed in key areas. |
28/07/2025 | 23/07/2025 |
| 1.6 | The pharmacy does not make contemporaneous Responsible Pharmacist (RP) records and it does not keep its RP records in line with requirements. |
All RP records are now made in real-time using our PMR system. The Superintendent Pharmacist audits RP logs weekly to confirm completeness and timeliness. Pharmacists receive refresher training quarterly. |
28/07/2025 | 23/07/2025 |
| 4.2 | The pharmacy does not manage its services safely or effectively. Its team members are not working in accordance with the pharmacy's Standard Operating Procedures. Its assembled multi-compartment compliance packs do not include an audit trail to show staff involved in the dispensing and checking process. So, the pharmacy is unable to provide adequate assurances that these have always been clinically or accuracy checked by a pharmacist before they are supplied. The lack of audit trail would also make it more difficult to identify those involved in the event of a future query or incident. |
Blister packs now include colour and shape descriptions which are inputted on the PMR system and printed on backing sheets. Backing sheets are initialled by both the dispenser and checking pharmacist, creating a clear audit trail. PILs are now sent routinely unless declined by the patient, if a patient declines PILs then a note is added to the PMR reflecting this. Blister pack processes are reviewed monthly by the RP to ensure ongoing compliance with SOPs. Staff are encouraged to voice any queries and suggest areas for improvement to RP and Superintendent. |
28/07/2025 | 23/07/2025 |
| 4.3 | The pharmacy does not keep records of fridge temperatures and therefore cannot demonstrate that medicines requiring cold storage are always stored appropriately and in line with requirements. |
Fridge temperatures are now recorded daily using a temperature log. Staff are trained to check min/max and reset after logging. Logs are reviewed weekly by the RP and any issues are escalated as per SOP. |
28/07/2025 | 23/07/2025 |
Pharmacy inspections
Inspection reports and learning from inspections